Aims: The ability to adequately visualise the airway is vital for diagnosis and management of upper aerodigestive pathology. The use of awake endoscopy in is nowadays considered a simple and routine procedure. The aim of this presentation is to outline the history and development of paediatric nasal endoscopy. Methodology: A literature review was performed with a summary of the history of nasal endoscopy and awake proceduralism with a focus on the paediatric setting. Results: Prior to the invention of the light bulb, examination of the nasal and oral cavity was limited by the requirement for illumination via mirrors and candles. The first uses of rigid endoscopes in nasal examination were recorded between 1901 to 1908, when Valentin, Reichert, Sargnon and Hirschmann utilised cystoscopes with modifications for the removal of polyps and foreign bodies. The development of fibreoptics allowed for the creation of the first flexible gastroscope by gastroenterologist Basil Hirschowitz in 1957. The first report of the use of a fibreoptic bronchoscope to evaluate and intubate an adult with acute epiglottitis was published in 1979. They were then deployed in the paediatric population with Vauthy and Reddy further outlining the use of fibreoptics in the trans-nasal paediatric examination as well as paediatric nasal intubation. The utility of flexible nasendoscopy to perform evaluation of nasal obstruction was later described in 1997. Furthermore, in 1998 Berkowitz described the role of awake flexible nasendoscopy in identifying upper aerodigestive pathologies in neonates, detailing its use in the successful diagnosis of nasal stenosis, laryngomalacia, glossoptosis, subglottic stenosis and choanal atresia. Conclusion: Throughout the 21st century, the implementation of awake endoscopy in the paediatric setting has continued to expand. This is primarily due to the development of increasingly durable and fine caliber rigid and flexible endoscopes which have allowed for both improved visibility and patient comfort.

Cocaine is a controversial albeit integral agent in sinonasal surgery, being used by almost two thirds of Australian Otolaryngologists. Its involvement in Moffett’s solution presents a logistical challenge due to its illegality, despite its effectiveness as an anaesthetic. Cocaine is a naturally occurring alkaloid and is the only local anaesthetic with vasoconstrictive properties. Used in a medical context for the first time in 1884, Dr Carl Koller and Dr William Halsted pioneered the use of cocaine in ophthalmic surgery and mandibular nerve blocks, respectively. Unfortunately, Dr Halsted became addicted to cocaine later that year, an unbeknownst adverse effect at the time. As cocaine use bloomed in the medical field in the early 1900s, so did the prevalence of cocaine addiction within the general population. Due to its highly addictive nature, cocaine use decreased for other medical procedures in the early 1900s with the development of safer agents, such as procaine. Despite these newer compounds, cocaine remained the primary choice for ENT surgeons, due to its effectiveness as a superior mucosal anaesthetic and vasoconstrictor, with a short time to onset and reasonable duration of action. This culminated in the development of ‘Moffett’s Solution’, a combination of cocaine, adrenaline and bicarbonate for local anaesthesia of the nose, described in 1941 by Major Arthur James Moffett of the Royal Army Medical Corps. Cocaine remains controversial in its use, due to its illegality, potential for addiction and systemic side effects such as dangerous arrhythmias, myocardial infarction and CNS toxicity including seizures. Thus, while cocaine is a superior local anaesthetic for surgical preparations, concerns regarding its safe storage at hospitals have recently emerged. Moffett’s solution was an inspiring innovation at the time and continues to be a popular choice in sinonasal procedures with consideration given to side effects based on the individual patient.

Emil Zuckerkandl was a Hungarian-born anatomist of the 19th century who contributed majorly to contemporary surgical anatomy, particularly of the head and neck. Zuckerkandl completed his medical studies at the University of Vienna in 1874 and later returned as an anatomical prosector, eventually being appointed Chair of the Vienna School of Anatomy. His initial academic interests were in nasal cavity anatomy, during which time he first described the ‘concha of Zuckerkandl’, a rarely-found small turbinate situated above the supreme nasal concha; and the ‘dehiscence of Zuckerkandl’, small bony dehiscence/s in the lamina papyracea of the ethmoid bone.(1) In his subsequent research career, Zuckerkandl dedicated much time to investigating the anatomy of the airway, pharynx and neck. Most famously, in 1902, he first described the ‘tubercle of Zuckerkandl’, the posterolateral projection of the thyroid gland recognised by head and neck surgeons for its intimate relationship to the superior parathyroid gland and recurrent laryngeal nerve. Today, Zuckerkandl’s name is associated with a variety of other anatomical structures throughout the body, from the ‘organ of Zuckerkandl’ of the chromaffin system to the ‘fascia of Zuckerkandl’ at the kidneys. However, his true legacy consists of his clinically-oriented attitude towards the study of anatomy – Zuckerkandl espoused that anatomy be studied not for its own sake, but rather for its value to clinical and operative practice. This is exemplified by his statement that “anatomy is the war map for the operations of the physician”. More than a century since his death, Zuckerkandl’s contributions to the anatomical study of the head and neck remain directly relevant to surgeons today. 1. Delbridge LW. Emil Zuckerkandl. In: Pasieka JL, Lee JA, editors. Surgical Endocrinopathies: Clinical Management and the Founding Figures. Cham: Springer International Publishing; 2015. p. 251-3.

Evolutionarily speaking, olfaction is our oldest sense. For millennia, smell has been used as a diagnostic indicator, stretching from antiquity with Hippocrates’ teaching on the distinct smell of liver failure to the modern day with increasing research into the use of electronic noses and gas chromatography to diagnose pulmonary diseases and cancer. In ancient China and Europe, the ‘miasmatic theory’ was predicated upon the belief that disease was transmitted through noxious air and foul smells. In 400BC, Hippocrates was strident in rejecting the prevailing belief of disease as a consequence of divine punishment, rather ascribing it to one’s squalid environment and the poisonous emanations contained within it. In the Middle Ages, the Black Plague was thought to spread due to the “bad air”, almost definitely the smell of gangrenous, necrotic tissue. This saw the rise of the distinctive beaked masks filled with aromatics, thought to cleanse the air of disease. Olfaction remained a central part of medicine all the way up until the mid 1800s, when germ theory arose and formed the basis of modern medicine. In the 1920s, the recognition of smells as volatile compounds led to the development of a microelectrode for measuring various scents, and in 1989 the concept of artificial olfaction was introduced to the world. Today, the ‘electronic nose’ has been used alongside artificial intelligence for odour classification. It has found increasing medical applications, such as detecting COVID-19 in breath samples, with potential for rapid, non-invasive, point-of-care testing. However, the good old-fashioned sense of smell as a diagnostic tool is still taught to medical students and clinicians alike. The unmistakable smell of malaena permeating the gastroenterology ward, the fruity notes of diabetic ketoacidosis, or the sour smell of alcohol shape a clinicians first impression and remains a valuable diagnostic tool in the armamentarium of the discerning doctor.

In the late 1800s and early 1900s, initial attempts at transcranial approaches to the pituitary gland were fraught with high mortality rates, rendering them impractical. Recognizing the need for a safer alternative, Schloffer proposed the transsphenoidal route to the sella turcica. In a groundbreaking achievement in 1906, Schloffer successfully removed a pituitary tumor using this approach. The method underwent several modifications, with A. E. Halstead's 1910 description of a sublabial gingival incision marking a significant step in the procedure's evolution. Between 1910 and 1925, Cushing, drawing on earlier suggestions, refined the transsphenoidal approach. He applied it to 231 pituitary tumor cases, achieving a mortality rate of 5.6%. However, as Cushing honed his skills in transcranial surgery, the mortality rate further decreased to 4.5%. The transcranial approach allowed for the verification of suprasellar tumors and improved decompression of the optic apparatus, leading to enhanced vision recovery and lower recurrence rates. Consequently, Cushing and many contemporaneous neurosurgeons shifted preference from transnasal to transcranial approaches. Norman Dott, influenced by his studies with Cushing in 1923, returned to Scotland and persisted with the transsphenoidal procedure. In the early 1960s, Gerard Guiot, introduced to the approach by Dott, published notable results, reigniting interest in the transsphenoidal method across Europe. Jules Hardy, incorporating intraoperative fluoroscopy and later the operating microscope, further refined the procedure. These innovations significantly enhanced efficacy and reduced surgical morbidity. With the advent of antibiotics and modern microinstrumentation, the transsphenoidal approach emerged as the preferred method for lesions confined to the sella turcica. This evolution, from Schloffer's pioneering work to contemporary modifications, underscores the historical and practical significance of transsphenoidal approaches in pituitary surgery.

Sigmund Freud, the father of psychoanalysis, suffered from what was considered to be a malignant tumour spreading from the back of his palate. He underwent numerous surgical interventions and radiotherapy over 16 years. Such a long survival in the face of apparent local recurrences casts a shadow of doubt over the diagnosis of cancer given to Freud. A review of his medical care shows that Freud was a habituated cigar smoker and user of cocaine. The medical records suggest that his oral disease was caused by excess tobacco intake. It is also noted that from the 1890’s onwards, Freud regularly used cocaine. It is possible that the progressive and slowly erosive disease process may not have been a malignancy but the necrotising effect of cocaine that is understood to cause facial destructive lesions. Freud had delayed diagnosis, discussion of which was hidden from him. He underwent a number of operations, treatment with radiotherapy and local electrocoagulation treatment. He had rehabilitation with increasing complex oral obturators which he termed 'The Monster'. Eventually in 1939 he self-euthanised with Morphine. The discussion presented covers issues of diagnosis, patient involvement in care, treatment options for oral carcinoma, chronic side effects of treatment and patient choice of life quality and duration.